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ALTERNATIVE TREATMENT FOR MANAGEMENTOF BENIGN PROSTATIC HYPERPLASIA (BPH)

Harshad Punjani
Asso. Prof. in Urology, Bombay Hospital Institute of Medical Sciences. Mumbai 400 020.

Twenty eight years ago when I started my Registrar Post in General Surgery only open prostatectomy was in fashion. Prostatic adenoma was enucleated either by transvesical route (Frayer’s prostatectomy) or by retropubic route (Millin’s prostatectomy). A urologist at that time was the one who could perform nephrolithotomy and remove staghorn calculus without damaging the kidney. Open prostatectomy at that time carried higher mortality and morbidity rate than a coronary by-pass surgery today.

Transurethral resection was being introduced to our country then. Results were not very great at that time since instruments were old fashioned. Incandascent bulb at the tip of telescope as light source and poor quality of underwater cutting diathermy were far from ideal. Very soon, however the scenario changed. Improved telescopes, fibre optic light source and better quality diathermy were made available. Transurethral resection of prostate (TURP) became the operation of choice for small and moderate size of prostatic adenoma. In the last 15 years even larger glands have been tackled by the TUR procedure. Today, it has replaced the open surgery in 90% cases of prostatic enlargement. The mortality and morbidity rate has gone down and the hospital stay of the patient has also become reduced. It became so popular with the patients that when the doctors used to advice the patient a prostatic surgery, the patient at once would ask the treating surgeon, if he can perform the surgery endoscopically or not. Many newer methods have since been developed but each one is compared with the results of TURP. Thus TURP is considered by the urologists as a gold standard in treatment of obstructive prostatic enlargement.

Transurethral incision of the prostate (TUIP) was the other method in glands measuring upto 30 gm. In this procedure prostatic incision was made from bladder neck to verumontenum either at 6 O’clock position or at 5 and 7 O’clock position. Procedure was quick with much reduced mortality and morbidity. There was 3 to 10% failure rate and those patients required TURP.

During the last 10 years, other few major advances have taken place that are worth knowing about. Let us begin with the surgical advances.

LASER PROSTATECTOMY

Laser was introduced into urology about 10 years ago. Laser is an abbreviation of light amplification by stimulated emission of radiation. Energy was new with precise control and predictable target effect. Procedure was easy to learn for the surgeon and the patient was well benefited by having a short hospital stay as well as a rapid recovery. ND-Yag laser was found to be ideal for urology. Initially non contact mode of energy was utilised but soon given up since results were not as per the expectations. Now a contact evaporation of the prostate is in vogue. This gives good results in prostate weighing upto 30 gm which forms a major chunk of obstructive prostate glands. Prostate glands, of the weight between 30 and 80 gm. can be done by Laser assisted TURP. In this procedure, non contact Laser is given to the whole adenoma. Tissue is then resected to create a sizeable cavity with minimal blood loss. The walls of the resected cavity is again treated with non contact Laser to take care of residual tissue and toachieve final haemostasis. Thus Laser prostatectomy has multiple advantages over TURP.

Only disadvantage is the cost which is almost double than that of TURP. Recently Holmium laser is under extensive trial and has shown promising results. Intra prostatic laser coagulation (ILC) is also another new concept widely tried in Germany. In this procedure laser probe pierces the prostatic adenoma. Laser energy is then given to the adenoma sparing the urethral epithelium. Though the patient takes a little longer time to pass urine, he is spared of irritative symptoms.

Intra urethral prostatic stents

Excellent quality prostatic stents are now available. They are bio-adaptable. They are made up of metal Titanium and are similar to the stents in coronary artery except for the size. They are placed endoscopically from bladder neck to verumontenum. They expand to 36 fr. size while coming in contact with the body temperature (thermo expandable). Stents can be placed under sedation and local anaesthesia. This procedure is excellent for high risk patients and for younger patients who are not ready to compromise with their potency. The cost of the stent is between Rs. 35,000 and 50,000. Stent migration and epithelium proliferation within the stent remains a disadvantage.

High intensity focused ultra-sound (HIFU)

HIFU uses ultra-sound frequencies of 4 MHZ with a power density of 1680 per cube cm. This method achieves heating up to 70 degree celsius in the targeted tissue resulting in coagulation necrosis within 72 hours. This is followed by cavitation within 14 days. Trans rectal probe is used for the purpose. It is a well tolerated procedure and causes no harm to the rectum. It is performed under sedation. The procedure is costly and will cost almost 3 times that of TURP. Long term results are awaited.

Trans urethral needle ablation of prostate (TUNA)

In this method, a no. 22 fr. urethral catheter is placed under direct vision in the urethra. Two needles at 60 degrees angle to each other are located at the tip of the catheter. The needles are advanced into the prostatic adenoma by piercing the urethra. The radio frequency power of 490 KHz. is used to raise the intra prostatic temperature to around 100 degree celsius leading to intra prostatic cavitations. This method has been successful only in small-sized glands and in small number of patients. It has been practised in very few institutes with no long term results.

Trans urethral electro vaporisation of prostate (TUEVP)

This procedure uses a regular resectoscope device as in TURP but the Vaportrode substitutes the regular loop electrode. Vaporisation of the BPH tissue is performed in much the same way as in a regular TURP procedure except that the pull speed is much slower. Much higher power settings are used than TURP. The tissue is progressively vaporised to a suitable depth using multiple passes. The exact depth of the adenoma evaporated is difficult to perceive and thus it results in either inadequate evaporation or excessive evaporation with resultant bleeding. Higher power settings used to evaporate the gland has resulted in higher incidence of urethral strictures.

Prostatic hyperthermia and balloon dilatation of the prostate enjoyed a short term popularity. Poor long term results have not made these procedures popular. Medical Management

There has been a real breakthrough in the treatment of obstructive prostatic enlargement. Various medical products have been tried. But the two classes of drugs that have been found very useful are:-

The first group works on smooth muscle component of the prostate and prostatic capsule (dynamic component) and are the alpha receptor blockers.

The second group reduces the prostatic size by blocking the enzyme called 5 alpha reductase which is important in conversion of testosterone to dihydro testosterone (works on static component).

Other medical treatments consist of phytotherapy. This is very popular in Europe. Inadequate double blind trials and erratic effects have not made it popular in our country.

CONCLUSION

Thus today, the patient suffering from symptoms of benign enlargement of prostate has a wide choice of treatment available to him. However it is necessary that every patient must be informed about the alternative course of treatment available. They must be well informed about the advantages and the disadvantages of the treatment in question and the final choice can thus be the patient’s prerogative unless and until the surgeon seems to think otherwise. As we have seen earlier, the first choice is between surgical treatment and medical treatment. If medical treatment is chosen, then the choice will depend on selective alpha blockers, finesteride or a combination of both depending on the size of the gland.

There is also a wide choice amongst the surgical procedures. TURP and TUIP still remain the gold standards. VLAP (visual laser ablation of prostate) is the second choice because of the cost factor. It also remains the first choice in poor risk patients where absorption of irrigating fluid and bleeding can be detrmened. The prostatic stents come next. They are an excellent alternative in high risk patients or the younger age group patients (45 to 60 years) where medicines have failed and where the patients are not ready to compromise with their sexual function. Again, cost is also a factor here.

To sum it up, I would say that Urology has traversed horizons in the field of benign enlargement of Prostate. We still await newer techniques to come in and prove beneficial to our patients.

REFERENCES

  1. Lepor H, Stoner E. Long term results of medical therapies for Benign Prostatic Hyperplasia. Curr Opin Urol 1995; 5 : 18-24.
  2. Kabalin JN, Gill HS, Bite G, Woffe V. Comparative study of laser versus electrocautery prostatic resection : 18th month followup with complex urodynamic assessment. J Urol 1995; 153 : 94-98.
  3. Devonec M, Berger N, Perrin P. Transurethral microwave heating of the prostate from hyperthermia to thermotherapy. J End Urol 1991; 5 : 129-35.
  4. Schulman CC, Zlotta AR, Rasor SR, et al. Transurethral needle ablation (TUNA) : Safety, feasibility and tolerance of a new office procedure for the treatment of Benign prostatic hyperoplasia. Eur Urol 1993; 24 : 415-23.
  5. Williams G, Jager P, Mc Laughlin L. Use of stents for treating obstruction of the urinary outflow in patients unfit for surgery. Br Med J 1989; 298 : 1429-31.
  6. Fitzpatrick JM, Lynch TH. Phytotherapeutic agents in management of symptomatic Benign Prostatic Hyperplasia. Urol Clin North Am 1996; 22 : 407-12.

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